Request for Waiver of Nurse Aide Training and Competency ...

Texas Nurse Aide Registry

Request for Waiver of Nurse Aide Training and Competency Evaluation

Form 5507-NAR December 2022-E

Section 1. Application Information (to be completed by applicant) Note: The following form is for those who completed a nurse aide training program of 100 hours or more before July 1, 1989.

Read the following instructions before completing this form.

Attach a legible copy of a government issued photo identification that shows your birth date and the correct spelling of your name, your criminal history resultPslfaocreaNllolatasrtynSaemaleosrySotuamepveHrehraed from the Department of Public Safety publicsite.dps.ConvictionNameSearch

Complete all information in Section 1. Sign to verify that the information provided is correct.

Attach a completed Form 5506-NAR, Employment Verification, showing you provided nursing or nursing-related services at least every two years since July 1, 1989, to present for monetary compensation.

Attach an official or notarized copy of your certificate of completion or transcript that shows you completed a nurse aide training consisting of 100 or more hours before July 1, 1989. You may also have a program director, program trainer, or official keeper of records complete Section 2.

People who request to be placed on the Texas Nurse Aide Registry by waiver must meet eligibility requirements listed at Section 26 TAC 556.11(a)(1-5) of the Licensing Standards for Nurse Aides. No person listed as unemployable on the Employee Misconduct Registry

(EMR) or who has been found to have a conviction of a criminal offense listed in Texas Health and Safety Code Section 250.006 is eligible for the waiver. Chapter 250 and a list of convictions can be found at: statutes.legis.state.tx.us/Docs/HS/htm/HS.250.htm#00.

Email the completed form and required documents to the Texas Nurse Aide Registry nurseaideregistry@hhs..

Name (Last, First, Middle)

Maiden Name (if applicable)

Date of Birth (mm/dd/yyyy) Email Address

Mailing Address (Street or P.O. Box)

Area Code and Phone No.

Sex Male

City

Social Security No. Female

State

ZIP Code

Name of Training Program

Date Training Began:

Date Training Completed:

Signature ? Applicant

Date

Section 2. Affidavit of Training (to be completed by training program director, trainer or official records keeper)

Instructions:

Complete information requested below and provide authorized signature.

Notarize signature.

Return document to the nurse aide applicant.

Has the applicant successfully completed a nurse aide training course? ..................................................................................

Yes

No

The training course included

hours of nurse aide training.

Nurse aide training was completed before July 1, 1989. Dates of training were from

to:

Name of Training Facility

Area Code and Phone No.

Address (Street or P.O. Box)

City

State

ZIP Code

Name of Official Completing Form

Title

Signature ? Official

Sworn and subscribed to me on this

day of

in

County, in the state of

, 20 , .

Date

Signature ? Notary Public

Date Commission Expires Notes: The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without required documents. Tampering with, or attempting to, falsify a government record such as a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison

and a $10,000 fine.

Address:

Form 5507-NAR Page 2 / 12-2022-E

To meet waiver eligibility requirements, Nurse Aide Registry staff will complete the EMR check. However, the person requesting a waiver must obtain a criminal history check from the Texas Department of Public Safety (DPS)., Contact your local DPS office at https:// publicsite.dps.Conviction for instructions on how a person can get a criminal history check. You must submit your criminal history results along with the waiver Form 5507-NAR to receive approval to be placed on the Texas Nurse Aide Registry by waiver.

Did you: Sign the form? Include your criminal history results for all last names you have ever had, a legible photocopy of your picture identification showing

your birth date and the correct spelling of your name? Include completed Form 5506-NAR, Employment Verification, for each nursing or nursing-related service you provided for

monetary compensation at least every two years since July 1, 1989?

Did training program director, trainer or official records keeper: Complete Section 2? Sign the affidavit? Notarize the signature?

Did you know? You can verify certificate status by using the following link: emr.dads.state.tx.us/DadsEMRWeb/. You can download forms from our website: hhs.doing-business-hhs/licensing-credentialing-regulation/credentialing/

nurse-aide-registry/nar-forms.

Email the completed form and required documents to the Texas Nurse Aide Registry at nurseaideregistry@hhs..

With a few exceptions, you have the right to request and be informed about the information that the Texas Health and Human Services (HHSC) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask HHSC to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To contact the Nurse Aide Registry call 512-438-2050 to find out about your information and your right to request correction.

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